'Prehabilitation' prevents functional decline of at-risk frail elders living at home

Despite decreasing disability rates, more than 7 million Americans 65 or older suffer from chronic disabilities that make it difficult to live independently. A new study shows that a 6 month at-home "prehabilitation" intervention to improve physical abilities was more effective in preventing declines and preserving functional abilities such as walking, dressing, and bathing than was a 6 month health education program. At the end of 12 months, the "prehabilitation" group showed a 37 percent reduction in risk for new disabilities.

The results of the study, titled A Program to Prevent Functional Decline in Physically Frail, Elderly Persons Who Live at Home are published in the October 3 issue of The New England Journal of Medicine. The study, authored by Thomas M. Gill, M.D., at the Yale University School of Medicine Department of Internal Medicine and his colleagues,* was funded through the Claude D. Pepper Older Americans Independence Center, the National Institute on Aging, and the Gaylord Rehabilitation Institute.

"This is an intervention that could make a big difference for many frail older persons wishing to remain independent while living at home," said Evan Hadley, M.D., NIA's Associate Director for Geriatrics and Clinical Gerontology.

A physical therapist assessed each of the 188 participants' levels of impairment and home environment to determine eligibility for the study. People were considered physically frail if they required more than 10 seconds to walk back and forth over a
10-ft. course or if they could not stand up from a hardback chair with their arms folded.

Participants in the "prehabilitation" intervention met with a physical therapist an average of 16 times over 6 months. They exercised their arms and legs with resistant elastic bands to improve their balance, muscle strength, transfer skills, and mobility.

Participants were instructed to perform balance exercises once a day and conditioning exercises 3 times a week after the physical therapist determined that the participants were able to perform the exercises safely and effectively without supervision. The physical therapist reviewed participants' daily exercise calendars at each visit and called participants monthly for 6 additional months. The program also included environmental home modifications to facilitate independent function and prevent injuries.

Participants in the health education group, who acted as the control group, met with a health educator during 6 monthly home visits and reviewed good health practices, such as proper nutrition, management of medications, physical activity, and sleep hygiene. The health educator called monthly for 6 additional months.

After the 6-month follow-up program concluded, researchers calculated summary disability scores for each participant, which ranged from 0 to 16 based on eight separate activities, such as walking, using the toilet, and getting in and out of a chair or bed. Higher scores indicated more severe impairment in a function or functions. The average disability scores in the intervention and control groups were similar, respectively 2.3 and 2.8 at baseline. The disability scores were significantly different between the two groups at 7 and 12 months. At 7 months, the "prehabilitation" group scored 2.0 and the health education group scored 3.6. At the 12-month follow-up, the "prehabilitation" group scored 2.7 compared to the health education group's score of 4.2.

The benefits of the intervention were greatest among people with moderate frailty; the intervention did not have significant effects in people with severe frailty.
The reasons for this were unclear, according to the study. The cause of disability in elderly people is complex and is thought to involve the interplay of impairments in physical ability, cognitive status, and intervening events.

The "prehabilitation" intervention's cost of $2,000 per person was moderate compared with cost of other treatments; further evaluation is needed to determine the program's cost effectiveness and to identify the means by which it exerts a beneficial effect, study authors said. The study was not designed to measure the impact of the intervention on the need for nursing home admission and other long-term care; this will require a larger study.

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* Other authors of the study included Dorothy I. Baker, Ph.D., R.N.,C.S., Peter N. Peduzzi, Ph.D., and Amy Byers, M.P.H., from Yale University School of Medicine's Department of Epidemiology and Public Health; Margaret Gottschalk, P.T., M.S., from the Department of Rehabilitation Services, Yale-New Haven Hospital; and Heather Allore, Ph.D., from the Yale University School of Medicine's Department of Internal Medicine. Peter N. Peduzzi, P.D. also is affiliated with Department of Veterans Affairs, Connecticut Healthcare System, West Haven, Conn.

The NIA, part of the National Institutes of Health, leads the Federal effort supporting basic, clinical, epidemiological and social research on aging and the special needs of older people.

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